F0609

D

Failure to Timely and Accurately Report Abuse and Poisoning Allegations

Farmington, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely and accurately report multiple allegations of abuse and poisoning to the State Agency and law enforcement, and to submit required five‑day investigation reports. For one resident with severe cognitive impairment, unclear speech, and dependence on staff for most care, the facility submitted an FRI that only stated a CNA was in the room caring for the resident’s roommate for an extended period of time and did not identify the specific allegation of mistreatment. Internal witness statements, later found misfiled in other FRI folders, documented that the cognitively intact roommate reported seeing the CNA bent over the resident, holding her wrists down, and that the resident appeared upset. Another statement documented that during an interview the resident seemed nervous and reluctant to speak, and that her nails were not clipped, which conflicted with the CNA’s account that he had clipped and cleaned her nails. These details, including the allegation that the CNA held the resident’s wrists tightly and later spoke with the roommate to say he would never hurt a resident, were not included in the documentation submitted to the State Agency or in the facility’s investigation summary.

The surveyors found that the facility’s documentation for this incident was inaccurate, incomplete, and disorganized. The FRI reported the incident as occurring on one date and being discovered the following day, but witness statements showed the allegation was initially reported to the former DSS on an earlier date and identified a different date and time of occurrence. The facility’s investigation summary stated that a skin and pain assessment was completed immediately, but the only skin assessment located for the resident around that time was dated prior to the alleged incident, with the next assessment not until many days later. The FRI also indicated there were no witnesses and that law enforcement and other agencies were not notified, despite internal witness statements describing specific observations of the CNA’s actions and the resident’s demeanor. When interviewed, the Administrator could not explain the inaccurate, unorganized, and misleading documentation, the omission of the allegation that the CNA held the resident’s wrists, the failure to notify police, or the delay in reporting the allegation to the State Agency.

The facility also failed to timely and fully report separate allegations made by another resident with intact cognition and a diagnosis including schizoaffective disorder. In one incident, this resident reported to an LPN that a CNA raped her while providing care; the LPN’s incident report documented this allegation and showed the DON was notified the same day and the Administrator the following day. However, the investigation summary submitted to the State Agency only stated that the resident felt someone entered her room and did something to her and identified the CNA, without mentioning the specific allegation of rape. There was no indication that law enforcement was contacted regarding the sexual abuse allegation, and the Administrator later acknowledged that the allegation of rape was not reported to law enforcement and did not explain why it was omitted from the report and investigation summary.

Additional failures occurred when the same cognitively intact resident alleged that another resident poisoned her coffee and later alleged that an LPN poisoned her, prompting the resident to call 911 to be transferred to the hospital. For the allegation that another resident poisoned her coffee, the FRI showed the incident was discovered in the morning but not reported to the State Agency until 12 hours later, and no five‑day investigation was submitted within the required timeframe; the Administrator confirmed an investigation was not completed and could not explain the failure. For the allegation that the LPN poisoned her, the FRI documented that the incident was discovered in the afternoon and not reported to the State Agency until 22 hours later. In interviews, the Administrator stated that staff were to contact her immediately for any abuse allegation and that all such allegations were to be reported to the State Agency within two hours and to law enforcement when abuse was involved, but she did not provide explanations for the delays in reporting or the missing and incomplete investigations identified by surveyors.